Pediatric emergency medicine trisk 3669 3669

FIGURE 114.2 Upper lid eversion. Note that patient is looking down throughout procedure. In
frame C, the swab is being rolled clockwise to engage skin and indirectly lift lash line. In frame
E, the swab is being pushed downward as the examiner lifts the lashes upward in the opposite
direction. In F, note that patient is wearing a contact lens.

Evaluate the Pupils and the Extraocular Movements
Examine for symmetric shape and size of the pupil, as well as responsiveness to
direct and consensual light exposure. The presence of an afferent pupillary defect
suggests the possibility of serious eye injury. This can be tested with the swinging
flashlight test (see Chapter 29 Eye: Unequal Pupils ). Evaluate for pain or
limitation of eye movement, which may suggest muscle entrapment, nerve palsy,
or retrobulbar hemorrhage.

Evaluate the Anterior Surface of the Eye
Inspect the conjunctiva and sclera for hemorrhage, trauma, or foreign body. With
the patient sitting upright, examine the anterior chamber for grossly visible
layered blood. Slit-lamp examination, preferably by an ophthalmologist, is
required for evaluation of microhyphema.
Once an open-globe injury and a hyphema are ruled out, the administration of
topical anesthetic should be considered. A drop of proparacaine 0.5% or
tetracaine 0.5% may have diagnostic and temporary therapeutic usefulness. The
child who is crying and refusing to open his/her eyes may be compliant just a few
minutes after the instillation of a topical anesthetic. Any patient who is made
more comfortable by the instillation of topical anesthetics likely has an ocular
surface problem (conjunctiva or cornea) as a cause of pain (but it does not rule
out concomitant deeper injuries). Topical fluorescein is used as a diagnostic agent
to stain the affected area in order to evaluate for corneal abrasions. Fluorescein is
available as impregnated paper strips and as a solution combined with a topical